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Based on clinical record review and staff interview, the facility failed to ensure a plan of care was developed for 1 of 30 patients (Patient #2) for identified pain on admission. The facility failed to substantiate the implementation of the patient care plan / treatment, for 3 of 30 sampled patients (#3, #4 and #5).

The findings include:

1. Review of the electronic clinical record for Patient #2 revealed an admission on 4/12/14 with diagnoses that include suicidal ideations, & off meds and non-compliant.
The nurse identified the patient to have pain on initial assessment and documented: having pain -yes; has pain at level of 7 of 10 scale. The nurse documented in the assessmet note that on admission the patient had a left wrist brace and voiced pain of 7/10 (scale 1 to 10, 10 being the worse pain level), for which the patient was medicated. Review of the care plans in the file revealed there is no developed and established plan of care in place for the management of Patient #2's pain.


2. Review of the facility policy & procedure for assessments and re-assessments revealed under Psychosocial history: It is the Social Workers responsibility to review and update the psychological components of the nursing initial bio-psychosocial assessment and document in the progress note any additional or missing information that has been communicated through consultations. In additional the Social Worker will document conclusions and make recommendations for treatment plan based on the current information from Psychosocial Assessment.
Under Progress Assessment / Reassessment the Policy documents, Progress Assessments/Reassessments are completed by the nurse on the Inpatient Unit / CSU. The focus is on progress towards the patient ' s treatment plan / nursing plan goals; A progress assessment identifies progress or lack of progress towards a specific goal / objective over a designated time frame, and the assessment includes the patient ' s perception of his / her progress or lack of his /her own progress.

a. Review of the clinical record for Patient # 3 revealed an admission on 4/11/14 with diagnoses including suicidal ideations. Review of the treatment plan dated 4/11/14 reveals a goal for the patient to verbalize 2 self-confirming statements about self.

Review of the nursing & social service notes from admission (4/11/14) to discharge on 4/14/14 with the RN Supervisor revealed there is no evidence the goals were addressed in terms of whether the patien achieved or did not achieve. Interview with the RN supervisor viewing the e-record on 4/16/14 at 10:56 AM verified there is no documentation regarding the status of the goal. There is no way to determine if the goal to self-affirmation was reached. The Director of Nurses said on 4/16/14 at 10:55 AM the social worker notes would have the documentation addressing the self-affirmation goal. Review of the social workers failed to disclose evidence addressing the status of the goal.

b. Review of the clinical record for Patient #4 revealed an admission on 4/11/14 at 2:33 PM with diagnoses that includes Depression and Homelessness. Review of the treatment plan reveal documented, by the SW (social worker) on 4/11/14, goals to include "will state 2 ways patient can replace negative self talk in order to improve his mood and help him to focus on his recovery goals". The nursing & social worker notes were reviewed with the RN Supervisor who verified there is no evidence the goal of replacing negative self talk was reached. Interview with the director of Social Work revealed the status of the goal would be documented in group therapy. There was no evidence of documentation of the goal in the group therapy notes.

c. Review of the clinical record for Patient #5 revealed an admission on 4/07/14. Review of the admission treatment plan disclosed the goal, Patient will identify 3 components of patient's daily routine. Review of the Social Worker notes & group therapy notes from admission to discharge of the patient revealed there is no evidence the goal for the patient to identify 3 components of daily routine was addressed/or met.

Based on staff interview and clinical record review, it was determined the facility failed to ensure the Pharmacy Policy and Procedures and By-Laws are implemented related to: timeframe for authentication on/signature of Verbal Telephone Orders. This failure affected 8 of 30 sampled patients (#5, #7, #10, #21, #22, #23, #25 and #28), and Safe drug storage. The nursing staff failed to follow the Policy for medication administration which affected patient #13.

The findings include:

1) The Policy and Procedure titled: Medication Prescription, Preparation, Monitoring of Medication under provision D and Q documents, the controlled medications must be double locked at all times.

Observation on the East Wing 4/14/14 at 11:00 AM revealed the door to the medication room was left, and the controlled medications were not double locked.


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(2) During the review of the closed electronic medical record of Patient #10, on 04/16/14, it was noted an admission date of 12/03/13. Review of the clinical record revealed physician's Electronic telephone Orders (TO) dated 12/18/13 for Ativan 2 mg IM or PO for Agitation, Haldol 5 mg PO or IM ETO (PRN Now) for Agitation and Benadryl 50 mg PO or IM ETO (PRN Now) for Agitation. The review of the clinical record revealed the physician did not sign the medication telephone orders until 01/03/14.
The Medical By-Laws document, "Emergency treatment orders are to be authenticated within 24 hours; other routine orders are to be authenticated within 48 hours.

(3) During the review of the electronic medical record of Patient #21 on 04/16/14 it was noted an admission date of 04/03/14. The record review revealed a physician's electronic Emergency Telephone Order (ETO) dated 04/04/14 for Risperdal 1 mg PO ETO give one X 1 only, and Ativan 2 mg PO give now 1 X for agitation. Further review of the clinical record revealed the physician did not sign off on the medication orders until 04/08/14, 4 days/96 hours after the order was written, violating By-Laws standards.

(4) During the review of the electronic medical record of Patient #22 on 04/16/14 it was noted an admission date of 04/05/14. Review of the record revealed a physician's Electronic Telephone Order (TO) dated 04/12/14 for Geodon 20 mg IM Stat (PRN/as needed Now) for agitation. Further review of the clinical record revealed the physician did not sign off on the Medication Telephone Order until 04/14/14 (2 days later). By-Laws standard requires 24 hours.

(5) During the review of the electronic medical record of Patient #23 it was noted an admission date of 04/07/14. Further review of the record revealed a physician's Electronic Emergency Telephone Order (ETO) dated 04/08/14 for Haldol 10 mg IM ETO Now, Benadryl 50 mg IM ETO Now for Agitation. Review of the clinical record revealed the physician did not sign off on the Emergency Medication order until 04/10/14 (2 days/48 hours later.

(6) During the review of the electronic medical record of Patient #25 it was noted an admission date of 04/10/14. The review of the record revealed a physician's Electronic Emergency Telephone Order (ETO) dated 04/10/14 for Geodon 20 mg PO or IM for Thought disorder, and Benadryl 50 mg PO of IM ETO Now, and Ativan 2 mg PO or IM ETO Now for thought disorder. Further review of the clinical record revealed the physician did not sign off on the Emergency Telephone medication orders until 04/14/14.

(7) During the review of the electronic medical record of Patient #28 on 04/16/14 it was noted an admission date of 04/09/14 with diagnoses of Schizophrenia With Paranoia. Further review of the record revealed a physician's Electronic Telephone Order (ETO) dated 04/09/14 for Haldol 10 mg PO or IM Stat (PRN Now) for Thought Disorder, and Benadryl 100 mg PO or IM Stat (PRN Now) for Thought Disorder. Further review of the clinical record revealed that the physician did not sign off on the medication orders until 04/14/14.


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(8) Review of the electronic clinical record for Patient #5 revealed an admission of 4/7/14. The record revealed a physician medication verbal order for Geodon 20 mg PRN q 8 hr (every 8 hours as needed) on 4/12/14 at 7:59 AM. The physician order is signed and dated on 4/14/14. The orders of 4/12/14 are signed by the physician, but it could not be determined when as the orders are note dated. The RN supervisor agreed the Geodon order is signed after the 24 - 48 hour period and other orders had no time so it could not be determined.

(9) Review of the clinical record for Patient #7 revealed an admission of 3/4/14. Review of the record revealed verbal physician orders on 3/4/14 for Tylenol as needed and Depakote 500 mg twice daily. The physician signed the verbal orders on 3/12/14. The policy requires routine Telephone orders to be signed/authenticated within 48 hours. This order was signed 8 days later. The review revealed a verbal physician order for Zyprexa 20 mg at bedtime (qHS), written on 3/6/14 at 9:24 AM, and signed on 3/12/14. This order was signed 6 days after it was given by Telephone, and not within 48 hours. The RN supervisor agreed the orders are not signed within the required timeframe.

(10) Review of the policy for "Medication: Prescription, Preparation, administration, and Monitoring of Medication revealed under G section, Accepted nursing techniques i.e. hand handling, counter cleanliness, are to be used to pour /administer medication. Use the SIX (6) rights: right patients, right dose, right medication, right time, right route and right documentation." An additional policy under N. revealed "The same nurse, who pour the medications using the electronic MAR is responsible for administering the medication. Use medication cards only to identify the patient."

Medication observation pass, observed on 4/15/14 at approximately 7:46 AM, performed by the licensed practical nurse on the East wing revealed: the nurse opened the 3rd drawer down of the medication cart to reveal 3 cups with medications pre-poured in the cups. Upon inquiry, the nurse said this is how she does it. The nurse said at approximately 8:05 AM, this is usually always the way she does it (pre-pours medications), as the patients sometimes come to the desk quickly and want their medications. When the 4th drawer was opened, there was another cup with pre-poured medications in it & no label on the cup to identify the medication. The nurse said when she comes in the mornings she gets meds ready for the patients.

Interview with the DON (director of nurses), on 4/15/14 at approximately 9:20 AM revealed the nurses are allowed to pre-pour medications for all patients at a specific time (i.e. 8 AM) as this is their process. There is no policy or procedure in place establishing pre-pouring the medications as a process. The DON said the nurse would have a copy of the MAR and census with patient picture on it with them on the medication cart, would check the patient armband and check name of patient.

Interview with the facility's pharmacist (Pharmacy Director), on 4/15/14 at approximately 9:25 AM revealed the practice is for nurses to review the MARs when medication is due, not prefill the cup, and administer to each individual patient for that specific time. He said pharmacy staff are not part of the monitoring of nurses administering medications to the patients. He concurred this practice is risky; 'if there are pre-poured medications, a mistake could easily be made". He said he was not aware of how the nurses are administering the medications.
The pharmacist said an order is obtained from the physician, printed, typed into computer (usually facility software), pharmacy fills the medications, put on label, fill in unit doses, put in Ziploc bag (if not in multi-dose, will put in bottle) dispensing enough for 8 days. Each patient care unit has a med cart with separate bin for each patient; the nurse will look at the MAR and provide meds to the patient. He said he assumed the nurse opens the medication at the time of administration and he was not aware of meds being pre-poured. He agreed pre-pouring medications for several patients at a time is unsafe and risky and does not follow the standard of practices related to the patients ' 6 rights of medications administration (right patient, dose, medication, time, route, & documentation).

Interview with the Director of Quality Assurance on 4/15/14 at 10:06 AM revealed she comprehends the risks in preparing medications for several patients at the same time and that it could be dangerous.
During interview with the Medical Director on 4/17/14 at 11:10 AM he said to pre-pour several medications for different patients he agrees is not safe, and there is room for error. He also said the nurses should follow the procedure to prepare and administer medication to one patient at a time.

Review of the facility policy & procedure for the medication administration process revealed: the nursing staff must administer to only one patient at a time and avoid all distractions; Additional staff will be used to ensure other patient's access is minimized during medication administration to each patient.

(11) Observation prior to and during medication observation pass on 4/15/14 at approximately 7:57 AM with the licensed practical on the East wing revealed, the nurse had pre-poured the medications for Patient #13and identified 2 red oval gel-like capsules as Colace 100 mg each. She said the patient gets 2 to make 200 mg, 100 mg each. Review of the physician order and the printed electronic Medication Administration Record (MAR) revealed the patient is only to receive one capsule of 100 mg. This was reviewed with the nurse who said 'am I bad' .

Based on observation conducted on 04/14/14 it was determined the condition of the physical plant and the overall hospital environment is not maintained in a manner that the safety and well-being of patients are assured.

The findings include:

During the initial observation tour of the West Unit on 04/14/14 at 10:40 AM, accompanied by the Director of Nursing (DON), the following environment issues were noted:
1) Room #W-237: Patient closet interior is covered with graffiti and curse words, 1 of 2 window blind controls is broken; sharp metal edge protruding from window blind control; door stop broken and a metal bolt protruding up from floor approximately 2 inches.
2) Room #W-238: One of two window blind controls is broken; entry door stop is broken off from floor resulting in a metal bolt protruding up from the floor. Patient's wood closet is heavily worn on inside and outside surfaces.
3) Room #W-242: Two of two window blinds controls are broken; sharp metal edge protruding from window blind control. Patient's wood closet is heavily worn on inside and outside surfaces. Patient's wood closet is heavily worn on inside and outside surfaces.
4) Room #W-245: Shower stall grout is turning black in color; room base boards located under the windows are peeling away from the wall. Patient's wood closet is heavily worn on inside and outside surfaces.
5) Room #W-249: One of two window blind controls is broken; sharp metal edge protruding from window blind control. Patient's wood closet is heavily worn on inside and outside surfaces.
6) Room #W-252: One of two window blind controls is broken; sharp metal edge protruding from window blind control. Patient's wood closet is heavily worn on inside and outside surfaces.
7) Room #W-264: One of two window blinds controls is broken; sharp metal edge protruding from window blind control. Patient's wood closet is heavily worn on inside and outside surfaces.
8) Room #W-265: Two mirrors located within the bathroom has areas of desilverization. Patient's wood closet is heavily worn on inside and outside surfaces.
9) Room #W-285: Window blinds controls are broken, and sharp metal protruding from controls. Patient's wood closet is heavily worn on inside and outside surfaces.
10) Observation disclosed the Supply Room (located behind the nurses desk) is not secured and is potentially accessible to patients. Observations revealed a metal storage cabinet with an exterior posted sign stating "keep locked at all times". Cabinet was unlocked and the interior contents revealed a case of shaving razors (200 razors). Also observed was an unlocked wall cabinet that contain 21 bottles of rubbing alcohol and hydrogen peroxide. The DON (Director of Nurses) stated, both cabinets should be securely locked at all times due to possible access by patients.
11) Medical Director/Lab Office: Room floor heavily soiled with numerous drops of dried brown matter. The weighing scale is heavily soiled with areas of dried brown matter, and a stethoscope was hanging from the soiled scale touching the soiled areas. Twenty Culture tubes were found to be expired with expiration dates including 2008 and 2010.
12) Laundry Room: Dryer lint screen is broken, and a possible fire hazard.
13) Resident Dining Room: One of three dining room tables is broken and large area of the wood is exposed. Numerous ceiling tiles surrounding the 4 air-conditioner vents are soiled and stained brown in color.
14) Patient Lounge Area: Nine patient lounge chairs were noted to have numerous large holes and tears. The holes are large enough to expose the inside contents/stuffing.
15) The soap dispenser in the East Wing Shower was found lying on the shower seat on 4/14/14 at 11:00 AM.

Based on observation and staff interview conducted on 04/14/14 and 04/15/14, it was determined the hospital failed to have a comprehensive infection control program that implements policies and procedures to maintain a sanitary food service department.

The findings include:

1) During the kitchen/food service sanitation tour, conducted on 07/14/14 at 10 AM accompanied by the facility's Food Service Manager, the following sanitation issues were found:
(a) The entry door to the walk-in refrigerator #1 is not shutting and sealing properly when the refrigerator door is closed. Due to this there is a large build-up and dripping of condensation at the entrance to the unit. There is potential for the contaminated condensation to drip onto food exiting and leaving the unit resulting in possible food borne illness and contamination. There is also the potential for the contaminated condensation to drip on the food service workers during the entering and exiting from the unit. Further observation of the floor area at the entrance to the walk-in refrigerator revealed large scrapes in the floor that confirmed the door is not fitting the unit properly, or it is the wrong door for the unit.
(b) The interior ceiling and refrigeration bases of the walk-in refrigerator #1, are heavily pitted and rust laden. There is the potential for the ceiling matter and rust to fall into foods being stored within the unit and result in possible food borne illness and food contamination.
(c) During the observation of the walk-in refrigerator, #1, it was found that expired foods are being stored and being utilized for patient food. Specifically it was discovered, 4 -five pound (20 pounds) containers of expired cottage cheese with a factory expiration stamped date of 04/06/14.
(d) During the observation of the walk-in freezer it was found there is a heavy accumulation of ice on both the interior and exterior unit. The ice build-up is approximately 2 inches thick and prevents the entry door to properly shut. The entry door was also observed to have the gasket rubber seal pulled off. Observation of the interior of the unit revealed numerous foods encased in ice build-up resulting is possible freezer burn.
(e) The wall area near the walk-in refrigerator have a large area of broken and missing wall tiles.
(f) The floor area of the kitchen in the food preparation area have numerous areas of broken and missing floor tiles.
(g) During the observation of walk-in refrigerator, #1, it was found the food storage shelves within the unit ae rust laden.
(h) During the observation of the dish machine service it was revealed the staff are currently washing dishes. Observation revealed there is no soap detergent within the base of the dish machine. Observation of the soap detergent revealed the container is empty and the alarm, to notify staff the soap detergent was empty, is not working.
(i) During the observation of walk-in refrigerator #2 it was found the ceiling interior is pitting and rusted. The fan cover of the refrigeration unit has a build-up of black matter.
2) During a routine observation of the Emergency Room Department on 04/15/14 at 2:45 PM 4 Styrofoam food storage containers and 6 small containers containing a bean salads sat upon the patient receiving desk. The contents contained sausage, ziti pasta with sauce, broccoli, the salads were 3-bean salad. The Behavior Health Technician who was on duty behind the desk stated food containers and salads are the facility's lunch meal and were delivered to the ER between 11:30 AM to 12 PM. The technician also stated, the meals are delivered daily and sit out at room temperature for hours and are served to new admissions to the hospital who have not eaten a lunch meal, and that the meals are discarded prior to the delivery of dinner meals to the ER. These dinner meals also sit out at room temperature on the counter for hours and are intended for patients admitted after 5 PM who have not eaten a dinner meal.
Further interview revealed this is a daily process and the staff is unaware that perishable foods require proper refrigeration at all times. Interview with Food Service Manager following the observation revealed she is unaware that perishable foods are being stored at room temperature and that patients are being served these foods after sitting out at room temperatures for hours. The manager further stated the meals are to be stored in the refrigerator that is in the ER department.
3) Following the 04/15/14 observation of the Emergency Room Department the facility's Infection Control Director approached the surveyor concerning the 04/14/14 and 04/15/14 observations and asked the surveyor to accompany her into the dietary department and review the violations. During the tour it was revealed the director does not tour the dietary department as part of the facility's infection control program. The director is unaware of food sanitation regulations and techniques that relate to infection control monitoring and investigations.